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OBJECTIVES: This study assessed the prevalence of and demographic variables associated with lifetime never-daily smoking in the United States. METHODS: Descriptive demographic data and logistic regression analyses were used to examine associations with never-daily smoking. RESULTS: Lifetime never-daily smokers constituted a significant minority of non-White smokers. There was a strong association between never-daily smoking and college education among young adults, particularly men. Although never-daily smoking was associated with initiation behavior among young smokers, it also represented a persistent pattern for some smokers, particularly non-Whites and Hispanics. CONCLUSIONS: The demographic distribution of never-daily smoking may have implications for developing culturally appropriate smoking prevention and cessation strategies.

In response to several influenza A(H1N1)pdm09 infections that developed in passengers after they traveled on the same 2 flights from New York, New York, USA, to Hong Kong, China, to Fuzhou, China, we assessed transmission of influenza A(H1N1)pdm09 virus on these flights. We defined a case of infection as onset of fever and respiratory symptoms and detection of virus by PCR in a passenger or crew member of either flight. Illness developed only in passengers who traveled on the New York to Hong Kong flight. We compared exposures of 9 case-passengers with those of 32 asymptomatic control-passengers. None of the 9 case-passengers, compared with 47% (15/32) of control-passengers, wore a face mask for the entire flight (odds ratio 0, 95% CI 0–0.71). The source case-passenger was not identified. Wearing a face mask was a protective factor against influenza infection. We recommend a more comprehensive intervention study to accurately estimate this effect.

Simple Summary In the spring of 2006, four human cases of parapoxvirus infections in Missouri residents were reported to the Centers for Disease Control and Prevention (CDC). We conducted surveys of herders and veterinarians, performed animal and environmental sampling and obtained sera from potential case-patients. We determined that, in general, infected persons may seek advice from veterinarians rather than physicians, thereby giving physicians less clinical experience. The initial perception of increased incidence in Missouri was likely due to reporting bias due to misdiagnosis and increased awareness due to recent publications. Basic personal protective measures are not being routinely utilized. Asymptomatic parapoxvirus infections in livestock may be common and warrants further investigation. Abstract In the spring of 2006, four human cases of parapoxvirus infections in Missouri residents were reported to the Centers for Disease Control and Prevention (CDC), two of which were initially diagnosed as cutaneous anthrax. This investigation was conducted to determine the level of recognition of zoonotic parapoxvirus infections and prevention measures, the degree to which veterinarians may be consulted on human infections and what forces were behind this perceived increase in reported infections. Interviews were conducted and clinical and environmental sampling was performed. Swab and scab specimens were analyzed by real-time polymerase chain reaction (PCR), whereas serum specimens were evaluated for parapoxvirus antibodies. Three case patients were found to have fed ill juvenile animals without using gloves. Forty-six percent of veterinarians reported having been consulted regarding suspected human orf infections. Orf virus DNA was detected from five of 25 asymptomatic sheep. Analysis of extracellular envelope gene sequences indicated that sheep and goat isolates clustered in a species-preferential fashion. Parapoxvirus infections are common in Missouri ruminants and their handlers. Infected persons often do not seek medical care; some may seek advice from veterinarians rather than physicians. The initial perception of increased incidence in Missouri may have arisen from a reporting artifact stemming from heightened concern about anthrax. Asymptomatic parapoxvirus infections in livestock may be common and further investigation warranted.

OBJECTIVE: This study sought to reassess the relationship between cigarette smoking and education. METHODS: Data from the 1983 to 1991 National Health Interview Survey for participants aged 25 years and older were used to plot the prevalence of current smoking, ever smoking, heavy smoking, and smoking cessation, as well as the adjusted log odds ratios, by years of education. RESULTS: The "less than high school graduate" category consisted of two groups with distinct smoking patterns: persons with 0 to 8 years and persons with 9 to 11 years of education. The latter were the most likely to be current, ever, and heavy smokers and the least likely to have quit smoking, whereas the former were similar to persons having 12 years of education. After 11 years of education, the likelihood of smoking decreased and that of smoking cessation increased with each successive year of education. These results persisted after the statistical adjustment for age, sex, ethnicity, poverty status, employment status, marital status, geographic region, and year of survey. CONCLUSIONS: The relationship between smoking and education is not monotonic. Thus, when evaluating smoking in relation to education, researchers should categorize years of education as follows: 0 to 8, 9 to 11, 12, 13 to 15, and 16 or more years.

To examine the impact of hospital mortality and intensive care unit (ICU) size on the performance of the Mortality Probability Model II system for use in quality assessment, and to examine the ability of model customization to produce accurate estimates of hospital mortality to characterize patients by severity of illness for clinical trials.Prospective evaluation of model performance, using retrospective data.Data for the simulation were assembled from six adult medical and surgical ICUs in Massachusetts and New York.Consecutive admissions (n = 4,224) to the Massachusetts and New York ICUs were studied. The mortality rate in the database was 18.7%.A computer simulation of several different hospital mortality rates and ICU sample sizes, using a multicenter database of consecutive ICU admissions, was utilized. We simulated 20 different mortality rates by randomly changing the outcomes at hospital discharge from "survived" to "deceased" and from "deceased" to "survived". Four sample size simulations used 75%, 50%, 25%, and 10% of the database. Ten replications of each mortality rate and samples size were constructed, and model calibration and discrimination were assessed for each replication. Model coefficients were customized, using logistic regression.Vital status at hospital discharge was the outcome measure among the ICU patient population. Model performance was assessed using the Hosmer-Lemeshow C statistic for calibration, and the area under the receiver operating characteristic curve for discrimination. Goodness-of-fit tests and receiver operating characteristic curve areas demonstrated that the models were sensitive to differences in hospital mortality, indicating that they are useful quality assurance tools. Goodness-of-fit tests were more sensitive than the receiver operating characteristic curve areas. The further the hospital mortality rate diverged from the original rate, the worse the performance of the model. Sample size had an impact on these results. The smaller the sample size, the less likely the model was to perform poorly. Model coefficients were successfully customized to demonstrate that improved model performance can be achieved when necessary for clinical trial stratification.Mortality Probability Model II models can be used to assess quality of care in ICUs, but the size of the sample should be considered when assessing calibration and discrimination.

Objective: During a nationwide measles epidemic in 2013, we conducted an investigation in Sanliurfa province to assess risk factors for measles infections. Methods: In a case-control design, we compared the history of hospital exposures for 189 randomly selected laboratory-confirmed patients (aged

Previous observational studies have reported protective effects of hand-washing in reducing upper respiratory infections, little is known about the associations between hand-washing and good hygienic habits and seasonal influenza infection. We conducted a case-control study to test whether the risk of influenza transmission associated with self-reported hand-washing and unhealthy hygienic habits among residents in Fujian Province, southeastern China.Laboratory confirmed seasonal influenza cases were consecutively included in the study as case-patients (n = 100). For each case, we selected 1 control person matched for age and city of residence. Telephone interview was used to collect information on hand-washing and hygienic habits. The associations were analyzed using conditional logistic regression. Compared with the poorest hand-washing score of 0 to 3, odds ratios of influenza infection decreased progressively from 0.26 to 0.029 as hand-washing score increased from 4 to the maximum of 9 (P < 0.001). Compared with the poorest hygienic habit score of 0 to 2, odds ratios of influenza infection decreased from 0.10 to 0.015 with improving score of hygienic habits (P < 0.001). Independent protective factors against influenza infection included good hygienic habits, higher hand-washing score, providing soap or hand cleaner beside the hand-washing basin, and receiving influenza vaccine. Regular hand-washing and good hygienic habits were associated with a reduced risk of influenza infection. These findings support the general recommendation for nonpharmaceutical interventions against influenza.

We investigated an outbreak of severe fever with thrombocytopenia syndrome (SFTS) that occurred during May and June 2010, to identify the mode of transmission. Contact with the index patient's blood was significantly associated with development of SFTS (P = .01, by the χ(2) test for linear trend); the frequency of contact with the index patient's blood increased the risk of SFTS in a dose-response manner (P = .03, by the χ(2) test for linear trend). We concluded that human-to-human transmission caused this cluster of cases.

To identify risk factors for a human orf disease outbreak in a village in Chongqing city.Standardized case-definition was set and a case-finding program was conducted among all the residents of the village. All the patients were interviewed using a standardized questionnaire and collected fluids in the skin rash for laboratory testing. A retrospective cohort investigation was conducted among all the village residents who introduced the black goats to analyze the risk of orf infection, in relation to the mode and frequency of contacts to the infected goats.We found 18 cases (including 16 suspected cases and 2 confirmed cases) among the members of 10 families that introduced the black goats. Village residents who had ever used their legs to grip the goats were nearly five times as likely to develop orf disease as those who did not (RR = 4.98, 95%CI: 1.34 - 75.27). Village residents who had ever washed and wiped the goats were three times as likely to develop orf disease as those who had not (RR = 3.09, 95%CI: 0.98 - 45.38). The frequency of contacts with the infected goats was associated with the risk of developing orf disease in a dose-response fashion (χ² test for trends: P = 0.006). Frequently wearing long trousers when dealing with the goats appeared as a protective factor (RR = 0.30, 95%CI: 0.15 - 0.78).This outbreak was caused by the introduced black goats which carried and infected by the orf virus. Direct physical contact with infected goats but without wearing protective clothing were risk factors for the development of human orf disease.

A hepatitis A outbreak in a primary school was reported by Gan County Center for Disease Control and Province (CDC) and an investigation was conducted to identify the possible source of infection and risk factors for transmission.A probable case was defined as having onset of jaundice (yellow urine, sclera or skin) or a 2-fold increase in Alanine aminotransferase with 2 or more, of the followings symptoms: anorexia, disgust of oil, abdominal pain, nausea, fatigue, vomiting, in students and staff of the primary school between 1 November 2008 and 14 February 2009. A confirmed case was IgM positive for hepatitis A, added on a probable case. We searched for cases through reviewing medical records in the township hospital and village clinics and conducting symptom screening among students or teachers. We also conducted a case-control study to compare the exposure histories of 19 cases and 53 anti-HAV-IgM negative controls randomly selected from those asymptomatic students in the same grade.21 cases from all the students was identified, with the attack rate as 3.5%. The epidemic curve showed the two peaks of the outbreak were 28 days apart, both indicating that they were related to the exposure of the source of origin. 74% of the case-students drank the unboiled Well B water, compared to 42% of control-students (OR = 4.0, 95%CI: 1.1 - 15). The total bacterial count was 600 cfu/ml and the total coliform was 23 MPN/100 ml in one sample collected from the well water.This hepatitis A outbreak was caused by drinking contaminated water in Well B. We recommended that all the schools should use chlorinated municipal pipe water. Public health authorities should strengthen the supervision of quality of water in schools.

To study a local hospital reported acute gastroenteritis in a boarding school on its source of infection, mode of transmission and risk factors of the infection.A suspected case was defined as who had developed diarrhea (≥ 3 times/day) or vomiting among teachers or students of the school, during April 19 - 30, 2010. A confirmed case was from a probable case plus tested positive for norovirus in stool specimens by using RT-PCR. Stool specimens of cases and environmental specimens were collected for laboratory diagnosis. In a case-control study, we compared exposures to sources of bottled water, consumption of bottled water, and hygienic habits of 220 probable or confirmed cases from April 21 - 23 in the peak of the outbreak, together with another 220 controls, with frequency-matched by school grade.20.3% of the 1536 students but none of the teachers developed the disease. 98.6% of the cases (n = 217) and 85.5% (n = 188) of the controls had drunk bottled water in the classroom (OR(M-H) = 12.3, 95%CI: 3.7 - 40.9). 47.9% (n = 104) of the cases and 41.5% (n = 78) of the controls had drunk unboiled bottled water in classroom (OR(M-H) = 3.8, 95%CI: 1.5 - 9.6). 47.9% (n = 104) of the cases and 48.4% (n = 91) of the controls had drunk bottled mixed water (boiled and unboiled) in the classroom (OR(M-H) = 2.8, 95%CI: 1.1 - 7.0). Stool specimens from 3 cases and one bottle of uncovered bottled water in classroom showed positive of having norovirus genotype II. Coliforms was cultured much higher rates than standard deviations in the bottled water. The factory making the bottled water was not licensed or having strict disinfection facilities.Bottled spring water contaminated by norovirus was responsible for this outbreak.

To identify the bacterial pathogen in food and the source of infection that might be responsible for a food poisoning outbreak.All the probable cases that had attended the banquet in a village of Sichuan province who had developed fever (≥ 37.5°C), diarrhea (≥ 3 times/day) and vomiting since August 1, 2009, were identified. A case-control study was conducted to identify the foods that might be responsible for this food poisoning event. 50 cases were randomly selected from the probable cases and 50 controls were randomly selected from those without the symptoms.The attack rate of this food poisoning event was 43.4% (132/304). 86.0% (43/50) of the cases and 34.0% (17/50) of the controls had eaten pork-mixed-vermicelli(OR = 12.0, 95%CI: 4.4 - 32). Data from further tests showed that dose-effect relation existing between eating pork mixing vermicelli behavior and the incidence rates(Chi-square trend: χ(2) = 21.06, P = 0.00) of the disease. 94.0% (47/50) of the cases and 68.0% (34/50) of the controls had eaten mushroom braising chicken (OR = 7.4, 95%CI: 2.0 - 27). Data from the crossover analysis showed that there appeared an effect modification between behaviors of eating pork-mixed-vermicelli and eating mushroom braising chicken. Three cases were detected carrying Salmonella blegdam from their anus swabs and the same bacteria type was also detected in the pork-mixed-vermicelli.This outbreak of salmonellosis was caused by Salmonella blegdam contaminated pork-mixed-vermicelli or mushroom braising chicken during food processing.

Background During March 2008, a college in Urumqi, capital of Xinjiang Uygur Autonomous Region in China, reported a measles outbreak, amid a city-wide outbreak involving >2700 cases. Methods Suspected case patients were defined as patients with onset of fever (≥38°) and rash between 7 March and 30 April 2008. Probable case patients were defined as suspected case patients with >3 days of rash or known exposure to someone with laboratory-confirmed measles. Confirmed case patients were defined as suspected or probable case patients with Koplik spots or positive titer for immunoglobulin M antibody. We conducted a case-control investigation to identify risk factors for transmission. Results We identified 162 suspected (attack rate, 1.9%), 99 probable, and 62 confirmed case patients. The epidemic curve indicated a point source initially, followed by person-to-person transmission. Approximately 63% of 90 probable case patients and 27% of 150 asymptomatic student controls randomly selected among classmates of student case patients visited internet cafes during the exposure period (odds ratio [OR], 4.5; 95% confidence interval [CI], 2.6-8.0); 66% of case patients and 45% of student controls reported close contact with a measles case patient (OR, 2.3; 95% CI, 1.3-3.9). In stratified analysis, visiting internet cafes (OR, 4.0; 95% CI, 1.5-11) remained significantly associated with disease, but contact with case patients (OR, 1.9; 95% CI, .79-4.4) became nonsignificant. Conclusions This measles outbreak was transmitted in internet cafes, followed by secondary transmission. Chinese universities should require proof of immunity or 2 doses of measles vaccine at college entry.

To explore the use of antiviral drugs in treating the hospitalized patients of novel influence A (H1N1) in Suzhou city during the 2009 - 2010 influenza pandemic, so as to make the proper use of antiviral drugs during influenza epidemics.We selected 3 municipal hospitals and reviewed the medical records of hospitalized patients suffered from novel influence A (H1N1) during June 2009 to March 2010, to gather antiviral use and other related information.98% (222/226) of the hospitalized patients received antiviral treatment. Among them, 92% (205/222) were given the neuraminidase inhibitor oseltamivir. However, only 18% of the patients who received oseltamivir were given the treatment within 2 days after the onset of the illness. Amantadine and rimantadine were not used for any of the hospitalized patients. Through interview on the physicians, we identified that delay in seeing care, misdiagnosis, delay in laboratory diagnosis were factors affecting the timely use of oseltamivir.The majority of the hospitalized patients suffered from novel influence A (H1N1) in the three municipal hospitals received oseltamivir treatment. However, in most occasions the drug was not used timely. Techniques of rapid detection and diagnosis for novel influenza A (H1N1) virus should be developed, and the diagnostic capabilities of the physicians improved, to increase the effectiveness of these antiviral drugs.

During June 2 - 8, 2009, 11 cases of the novel influenza A (H1N1) occurred in Sichuan Province, China. We investigated this outbreak to identify the source of infection, mode of transmission and risk factors for infection.The primary case, a U.S. citizen, developed disease on June 2. From June 3 to 5, she joined Tour Group A for a trip to Jiuzhaigou. We telephoned passengers of the three flights on which the primary case had traveled in China, and members of Tour Group A. We asked whether they had any influenza-like symptoms during May 27 to June 12. Health authorities placed passengers whose seats were within three rows of the primary case on flights and members of Tour Group A on medical observation, and isolated individuals if they developed symptoms. We used real-time RT-PCR to test the throat swabs from symptomatic persons for the novel influenza virus and defined a confirmed case as one with influenza-like symptoms and laboratory confirmation. A retrospective cohort investigation to identify the risk factors for infection was conducted. We interviewed all members of Tour Group A about their detailed contact history with the primary case.During June 5 to 6, 9 (30%) of the primary case's 30 fellow tour group members developed disease, compared with none of her 87 fellow passengers to Jiuzhaigou and 1 of her 87 fellow passengers on the returning trip (when several of the members of Tour Group A were symptomatic). 56% of the tourists who had talked with the primary case in close range (2 m) for ≥ 2 minutes developed disease, whereas none of the 14 other tour group members developed disease (RR = ∞;exact 95%CI: 2.0 - ∞). Having conversed with the primary case for ≥ 10 minutes (vs. 2 - 9 minutes) increased the risk by almost five fold (RR = 4.8, exact 95%CI: 1.3 - 180). Conversely, other kinds of contact, such as dining at the same table, receiving chewing gum from the primary case and sharing bus rides or planes with the primary case played no roles during this outbreak.This novel influenza A (H1N1) outbreak was caused by an imported case, and transmitted mainly via droplet transmission when the primary case was talking with her fellow tourists during a tour. These findings highlight the importance of preventing droplet transmission during a pandemic.

Vibrio cholera was extremely rare in Sichuan province(no cases in 2008). Any outbreak could indicate contamination through the food supply system. In July 2009, a hospital reported a cluster of 7 diarrhea patients;all attended the same banquet. One patient was confirmed to have Vibrio cholera (O139). We conducted this investigation to identify the source of this possible cholera outbreak.We defined a suspect case as any banquet attendee with diarrhea (≥ 3 times/day). A confirmed case was a suspect case with a positive Vibrio cholera culture. We took stool samples or rectal swabs from all attendees for cholera culture and interviewed 272 banquet attendees about foods they ate at the banquet and kitchen workers about food preparation.7.1% (24/337) of attendees developed cases within an average of 65 hours after eating. Three meals were served. All patients had the lunch whereas no patients only ate breakfast and/or dinner. Of 180 attendees who ate turtle meat 12% were case-patients, compared to 3.3% of 92 attendees who did not (RR = 3.6, 95%CI: 1.1 - 12). Of the 150 attendees who ate peanuts 13% were cases compared to 4.1% of 122 attendees who did not eat peanuts (RR = 3.1, 95%CI: 1.2 - 8.0). During preparation, the same utensil was used for fresh turtle meat and peanuts without washing in-between the process. Turtle meat and peanuts were stored for16 hours at room temperature after cooking before consumption. All 33 turtles originated from commercial production in another province.This outbreak was likely caused by poor food handling of commercially produced turtles. We proposed that to improve microbiologic monitoring of aquatic food animals, and raise the awareness of good handling practices at mass gathering in rural China.

To explore the score criteria of severe hand, foot and mouth disease (HFMD) cases and to provide evidence for unified criteria and treatment on severe HFMD cases.All severe cases and partial mild cases reported by two designated hospitals of HFMD in Fuyang during March to June, 2008 were scored by the methods of criteria constructed in advance. ROC curve was adopted to evaluate the score criteria and the gold standard was defined according to ICU, intubation and clinical outcomes, etc. Sensitivity, specificity and Youden's index were used to determine the division scores on critical, severe and mild cases.97% of the cases (34 cases) were scored less than 6 points. 88% of cases (24 cases) who were intubated or mechanical ventilated had the scores of 6 points or higher. 79% of deaths (11 cases) were scored 10 points or higher. The area of receiver operation characteristic (ROC) curve was 0.90 (95%CI: 0.83 - 0.98) between severe and mild cases and the area of ROC curve was 0.95 (95%CI: 0.92 - 0.98) between critical and severe, mild cases. When comprehensively considering the sensitivity and specificity, severe cases were best judged when score was 4 points (sensitivity, specificity and Youden's index were 0.94, 0.68 and 0.62 respectively). When score was 6 points, critical cases were judged very well (sensitivity, specificity and Youden's index were 0.92, 0.84 and 0.76 respectively).Score criteria could be quantified to determine the degree of seriousness and with high-value for diagnosis on HFMD.

To evaluate the effect of the aluminum hydroxide (Al-OH) adjuvant on the 2009 pandemic influenza A/H1N1 (pH1N1) vaccine.In a multicenter, double-blind, randomized, placebo-controlled trial, participants received two doses of split-virion formulation containing 15 μg hemagglutinin antigen, with or without aluminum hydroxide (Al-OH). We classified the participants into six age categories (61 years, 41-60 years, 19-40 years, 13-18 years, 8-12 years, and 3-7 years) and obtained four blood samples from each participant on days 0, 21, 35, and 42 following the first dose of immunization. We assessed vaccine immunogenicity by measuring the geometric mean titer (GMT) of hemagglutination inhibiting antibody. We used a two-level model to evaluate the fixed effect of aluminum Al-OH and other factors, accounting for repeated measures.The predictions of repeated measurement on GMTs of formulations with or without Al-OH, were 80.35 and 112.72, respectively. Al-OH significantly reduced immunogenicity after controlling for time post immunization, age-group and gender.The Al-OH adjuvant does not increase but actually reduces the immunogenicity of the split-virion pH1N1 vaccine.

To observe the promoting consciousness effect of electroacupuncture therapy on the patients with long-term coma caused by severe craniocerebral trauma.Twenty-nine cases with coma more than 3 weeks and Glasgow Coma Scales (GCS) of 8 or less were divided into an observation group (n=15) and a control group (n=14). They were treated with the same western medicine. In addition to ordinary treatment, the observation group was treated with electroacupuncture at Baihui (GV 20), Shuigou (GV 26), Yongquan (KI 1) etc. for 30 min and the needles were retained for 30 min, once each day.The average awake time and awake rate were 40.1 days and 73.3% (11/15) respectively in the observation group, which were higher than 51.8 days and 28.6% (4/14) in the control group.Electroacupuncture therapy combine with western medicine is more effective in improving consciousness of patients in coma caused by severe craniocerebral trauma.

To provide evidence-based recommendations to the government on strategies for reducing the impact of the imminent influenza pandemic, we conducted a survey on the personal protective and healthcare seeking behaviors of Beijing residents in the wake of the worldwide epidemic of the novel 2009 H1N1 influenza virus, and potential changes in these behaviors during a full-blown pandemic.We used a two-stage Mitofsky-Waksberg telephone survey to collect information for Beijing residents/= 18 years of age and weighted the sample by the census estimate of Beijing population for 2008. A structured questionnaire was used to collect information about the respondents' knowledge regarding the novel influenza virus, current personal protective and healthcare seeking behaviors during a full-blown influenza pandemic.286 Beijing urban residents were interviewed during May 15 to 18 (response rate: 62%). 77% (95%CI: 71% - 82%) of the residents that they would cover their sneezes at home, and 93% (95%CI: 89% - 96%) would do so in a public place. Of the residents would cover their sneezes at home, 66% (95%CI: 57% - 74%) would covered their sneezes by hand, 33% (95%CI: 25% - 42%) by facial tissue, and only 0.4% (95%CI: 0.1% - 2.9%) by sleeves. Similarly, of the residents would cover their sneezes at a public place, 64% (95%CI: 56% - 71%) would cover their sneezes by hand, 33% (95%CI: 26% - 41%) by facial tissue and 0% by sleeves. 46% (95%CI: 32% - 59%) of the residents would wash their hands after covering their sneezes with hand in public places, and 77% (95%CI: 64% - 89%) would do so at home. Higher percentages of residents would wear a mask (63%, 95%CI: 56% - 70%) and get vaccinated (43%, 95%CI: 37% - 50%) during a pandemic than under currently situation (3.5%, 95%CI: 1.7% - 7.0% for wearing a mask; 13%, 95%CI: 9.8% - 18% for getting vaccinated). 86% (95%CI: 81% - 89%) of the residents would visit a doctor for an influenza-like illness during a pandemic, similar to the percentage currently seen (76%, 95%CI: 70% - 81%). 71% (95%CI: 63% - 78%) of the residents would visit a doctor for influenza-like illness and would choose a tertiary medical center; with percentage (74%, 95%CI: 66% - 80%) similar to the one during a pandemic.Beijing residents need to be aware of the proper ways to cover their noses when sneezing (especially using their sleeves more), and to wash their hands. An effective plan to triage patients should be immediately established to efficiently utilize the limited healthcare resources, which would likely be further strained during a pandemic.

OBJECTIVE: We sought to determine the association of smoking status as a risk factor for reduced initiation and duration of breastfeeding.METHODS: The Missouri Pregnancy Related Assessment and Monitoring System collected a stratified sample of new mothers in 2005. Surveys were mailed, with telephone follow-up, and completed within 2 to 12 months after delivery. Respondents were classified as nonsmokers, smokers who quit during pregnancy, light smokers (≤10 cigarettes per day), or moderate/heavy smokers (>10 cigarettes per day). Multivariable binomial regression and Cox proportional hazards models were used to assess breastfeeding initiation and duration according to smoking status.RESULTS: Overall, 1789 women participated (weighted response rate: 61%). Approximately 74% of the women ever breastfed; 31% of the women ever smoked while pregnant. Compared with nonsmokers, the moderate/heavy smokers and light smokers were less likely to initiate breastfeeding, after controlling for sociodemographic characteristics, the presence of other smokers in the household, alcohol use, mode of delivery, and infant hospitalization. Compared with nonsmokers, the moderate/heavy smokers, light smokers, and smokers who quit during pregnancy were more likely to wean over time, controlling for the same covariates. There were no significant differences between nonsmokers and smokers regarding reasons for not initiating or ceasing breastfeeding.CONCLUSIONS: Mothers who smoked initiated breastfeeding less often and weaned earlier than nonsmoking mothers. Incorporating knowledge of the association between smoking and breastfeeding into existing smoking-cessation and breastfeeding programs could provide opportunities to reduce perinatal exposure to tobacco smoke, improve interest in breastfeeding, and address other barriers to breastfeeding that smoking mothers may face.

This outbreak was caused by droplet transmission., During June 2–8, 2009, an outbreak of influenza A pandemic (H1N1) 2009 occurred among 31 members of a tour group in China. To identify the mode of transmission and risk factors, we conducted a retrospective cohort investigation. The index case-patient was a female tourist from the United States. Secondary cases developed in 9 (30%) tour group members who had talked with the index case-patient and in 1 airline passenger (not a tour group member) who had sat within 2 rows of her. None of the 14 tour group members who had not talked with the index case-patient became ill. This outbreak was apparently caused by droplet transmission during coughing or talking. That airborne transmission was not a factor is supported by lack of secondary cases among fellow bus and air travelers. Our findings highlight the need to prevent transmission by droplets and fomites during a pandemic.

BACKGROUND:: Little is known about risk factors for typhoon-related injury. METHODS:: On 10 August 2006, Typhoon Saomei (one of the strongest typhoons on record) struck Southern China. We conducted a census in Longhua Village, Fujian Province to assess typhoon-related injury, and carried out a matched case-control analysis to evaluate risk factors. RESULTS:: Of the 3002 residents interviewed, 136 (4.5%) were injured, and 7 were reported by family members to have died (2.3 per 1000). Injuries were highest with the first peak of wind speed. Living in houses directly facing the sea, compared with living in the last row of houses, was associated with an increased risk (relative risk = 18 [95% confidence interval (CI) = 5.7-55]). Important risk factors were failure to reinforce doors or windows (adjusted odds ratio = 13 [95% CI = 2.4-76]), staying in a damaged room (8.7 [2.5-31]), and staying near a window or door (12 [4.1-38]). CONCLUSIONS:: Injuries with typhoon Saomei were related to both wind speed and failure to take specific preventive measures. Language: en

Objective. We examined the financial and social costs resulting from traumatic brain injury (TBI) in Missouri. Methods. We computed mortality rates from death certificates, the direct cost of TBI from hospital and emergency department (ED) visit charges, the social cost in terms of years of potential life lost (YPLL) using an abridged Missouri life table, and the indirect financial cost in terms of lost productivity due to premature death for all TBI and four major causes of TBI in Missouri. Results. During 2001–2005, a mean of 1,358 lives were lost due to TBI in Missouri. Four major causes—unintentional falls, motor vehicle traffic crashes, motorcycle crashes, and firearms—accounted for 88% of all TBI deaths. We estimated the annual direct medical cost of TBI at $95 million, or about $1.67 million per 100,000 Missourians. This cost increased by about 60% between 2001 and 2005. The four major causes of TBI accounted for 68% of all direct medical costs of TBI. We estimated the cost per hospitalization and ED visit at $6,948 and the indirect social cost at 48,501 YPLL. During this period, the mean age of TBI fatality was 44 years. We determined the lost productivity due to TBI mortality—$1.1 billion, or about $18.8 million per 100,000 Missourians—to be three times as high for males as for females. Conclusions. The types of costs covered in this study underestimated the total cost of TBI in Missouri, as we did not include outpatient care, rehabilitation, and drug costs. Nevertheless, we found the health and economic burden from medical care and mortality related to TBI to be substantial in Missouri.

Objective To determine risk factors for infection during a cryptosporidiosis outbreak in a rural Missouri community. Design Community-based case-control study. Setting Madison County, Missouri. Participants Case patients had laboratory-confirmed Cryptosporidium infection. Controls were randomly selected from the community. Interventions Pool water and municipal tap water were analyzed for Cryptosporidium oocysts. Univariate and multivariable logistic regression analyses were performed to evaluate potential risk factors. Outcome Measures Risk factors for cryptosporidiosis infection. Results In total, 56 case patients (median age, 7.0 years) who developed cryptosporidiosis from July 27 to August 30, 2005, and 76 controls (median age, 8.4 years) participated in this study. The main risk factors for cryptosporidiosis were attending child care center A or B (adjusted odds ratio, 42.11; 95% confidence interval, 4.88-363.57) and using a water park (adjusted odds ratio, 6.02; 95% confidence interval, 1.25-29.01). A pool-based case-control study indicated that the highest risk for infection was associated with eating at the pool (adjusted odds ratio, 7.26; 95% confidence interval, 2.57-20.48). The epidemiologic curve for cases without child care exposure peaked 4 days later than that for the child care–associated cases. Samples of water from the city water plant and the water park tested negative for Cryptosporidium oocysts. Conclusions Children attending child care center A or B were the likely sources of this cryptosporidiosis outbreak. Recreational pool water probably served as a vehicle for disease transmission in the community. Early recognition of first cases of cryptosporidiosis by health care providers (ie, pediatricians and family physicians) caring for children could play an important role in limiting community outbreaks.

The study objectives were to estimate the prevalence of chronic diseases and other health indicators for Hispanics in Missouri, and to compare their prevalence estimates with other racial/ethnic groups. DESIGN / SETTING / PARTICIPANTS: This study, conducted in public health and academic settings, used combined data from the 2002 and 2003 Missouri Behavioral Risk Factor Surveillance System and the 2003 Missouri County-Level Study. Data were post-stratified with Hispanic ethnicity as a separate group.Twenty health indicators were compared. Logistic regression was used to control for sociodemographic characteristics.Overall, 21.7% (95% confidence interval [CI] 13.4-30.0) of Hispanics, 19.8% (95% CI 14.4-25.2%) of non-Hispanic Blacks, and 12.2% (95% CI 11.2-13.1%) of non-Hispanic Whites had no insurance coverage. Hispanics were significantly less likely to report poor or fair health (12.1%, 95% CI 7.5-16.7%) than non-Hispanic Blacks (21.6%, 95% CI 17.2-26.0%), and less likely to report activity limitation (12.9%, 95% CI 8.0-17.9%) than non-Hispanic Whites (20.2%, 95% CI 19.1-21.2%). Controlling for sociodemographic characteristics, Hispanics had greater physician-diagnosed diabetes (OR = 2.0, 95% CI 1.0-3.3%) and Hispanics agedor = 50 were less likely to have no sigmoidoscopy or colonoscopy in the past five years (OR = 0.5, 95% CI 0.2-1.0%) compared to non-Hispanic Whites.Other than lower healthcare coverage and diabetes status, the health indicators for English-speaking Hispanics were similar to, or better than, non-Hispanic Blacks and Whites. However, these data may not represent all Hispanics in Missouri since health status between English-speaking and non-English speaking Hispanics may differ significantly.

This study was conducted to estimate the current prevalence of multiple sclerosis (MS) in Jefferson County, Missouri, USA, and to address community concerns about a perceived excess of MS around an active lead smelter. The study population consisted of the residents of Jefferson County, Missouri between 1998 and 2002. An aggressive MS case finding with capture-recapture analysis was used. The spatial clustering was examined using a spatial scan statistic. The capture-recapture analysis showed the case ascertainment to be 95%. The crude five-year period prevalence of MS in Jefferson County was 105 per 100,000 population (95% confidence interval [CI], 91-121), and 107 per 100,000 (95% CI, 95-119) when age-standardized to the 2000 U.S. population. No significant spatial clusters of MS cases were identified in the study area. The estimates of MS prevalence in Mid-western community of USA appeared to be comparable to estimates from other areas of similar latitude in the United States and Western Europe. The MS cases did not appear to cluster around the lead smelter.

This study used the Smoking-Attributable Mortality, Morbidity and Economic Cost (SAMMEC) software developed by the Centers for Disease Control and Prevention to assess the health consequences and economic burden due to smoking in Missouri. During 2000-2004, cigarette smoking resulted in 9,600 deaths (17.5% of all deaths), 132,103 Years of Potential Life Lost, and $2.4 billion in productivity loss annually in Missouri. These data show that Missouri suffers enormous human and financial losses from smoking.

BACKGROUND: Carbon monoxide (CO) poisoning can be fatal but is preventable. From October 2010 to February 2011, Anshan Prefecture reported 57 cases of non-occupational CO poisoning in District A, with two deaths. We conducted an investigation to identify risk factors and recommend preventive measures. METHODS: We defined a possible case of non-occupational CO poisoning as onset of at least two of the following symptoms: fatigue, headache, dizziness, nausea, vomiting, cyanosis, loss of consciousness, coma, and shock from October 1, 2010, to February 28, 2011, in a resident of Anshan Prefecture with non-occupational exposure to CO poisoning. We defined a probable case as onset of at least one of the following symptoms: cyanosis, loss of consciousness, coma and shock, plus at least one of the following symptoms: fatigue, headache, dizziness, nausea, vomiting, among possible cases. A confirmed CO poisoning case was a possible case or probable case plus hemoglobin (Hb) CO higher than 10%. We searched for cases by reviewing medical records and records of hyperbaric oxygen tank usage. In a case-control investigation, we compared home heating practices of 30 case-persons and 120 control-persons who were individually matched to each case by neighborhood. RESULTS: Overall, 56% (39/70) of case-patients' households burned coal for home-heating. In the case-control investigation, 40% (12/30) of case-persons' households compared with 5.8% (7/120) of control-persons' households placed stoves in bedrooms (Mantel-Haenszel odds ratio [ORM-H] = 11, 95% confidence interval [CI] = 3.0-41); 53% (16/30) of case-patients' households and 33% (40/120) of control-patients' households did not extinguish the fire before sleeping (ORM-H = 3.6, 95% CI = 1.1-12); 13% (4/30) of case-patients' households and 3% (4/120) of control-patients' households had not installed the ventilation pipe vertically (ORM-H = 7.3, 95% CI = 1.0-56). Overall, 77% (23/30) of case-patients' households and 39% (47/120) of control-patients' households had at least one of those three risk factors (ORM-H = 10, 95% CI = 2.5-40; population attributable risk percentage: 78%). CONCLUSIONS: Dangerous practices with coal-burning stoves inside the home accounted for the majority of CO poisoning incidents. Community health centers should provide instruction to and supervision of residents on proper installation and use of home heating stoves as well as inspection of installation. Language: en

Background: Obesity interventions are implemented at state or sub-state level in the United States (US), where only self-reported weight and height data for adults are available from the Behavioral Risk Factor Surveillance System (BRFSS). The prevalence estimates of overweight and obesity generated from self-reported weight and height from BRFSS are known to underestimate the true prevalence. However, whether this underestimation is consistent across different demographic groups has not been fully investigated. Methods: In this study, we compared the prevalence estimates of obesity (body mass index (BMI) 30 kg/m2) and overweight (BMI 25 kg/m2) in different demographic groups in the US from the National Health and Nutrition Examination Survey (NHANES) and BRFSS during 1999–2000. We also compared the rank orders of the obesity and overweight prevalence across different demographic groups from the two data sources. Results: Compared to NHANES, BRFSS underestimated the overall prevalence of obesity and overweight by 9.5 and 5.7 percentage points, respectively. The underestimation differed across different demographic groups: the underestimation of obesity and overweight prevalence was higher among women (13.1 and 12.2 percentage points, respectively) than among men (5.8 and -0.6 percentage points, respectively). The variation of underestimation was higher among men. A clear inverse association between educational attainment and obesity prevalence among non-Hispanic African American women was observed from BRFSS data. However, no such association was found from NHANES. While BRFSS can identify correctly the population with the highest obesity and overweight burden, it did not accurately rank the obesity and overweight prevalence across different demographic groups. Conclusion: Compared to NHANES, BRFSS disproportionately underestimates the prevalence of obesity and overweight across different gender, race, age, and education subgroups.

The relationship between interpregnancy interval and adverse birth outcomes (i.e., low birth weight, preterm birth, and small size for gestational age) was examined in three recent studies conducted in Utah and Michigan of the United States. These studies were conducted among different populations, used different study designs (i.e., cross-sectional and retrospective cohort designs), and addressed several other methodological limitations in the previously published literature. In addition, the data were stratified by, and controlled for, several maternal reproductive risk factors. A J-shaped relationship between interpregnancy interval and adverse birth outcomes was observed in all three studies. The risk for adverse birth outcomes is lowest when the interpregnancy interval was 18-23 months and increased when the interval departed from 18-23 months. This J-shaped relationship existed at levels of maternal reproductive risk factors and after these risk factors were controlled for using logistic regression. Based on the consistency of the findings from all three studies, it appears that the J-shaped relationship between interpregnancy interval and adverse birth outcomes is causal. This information can be used by health care providers and public health programs to counsel and educate women who recently gave births on reducing the risk for adverse birth outcomes by means of appropriate pregnancy spacing.

After almost two decades of decline, cigarette smoking is on the rise among adolescents in the United States. Although in recent years both AfricanAmerican and white adolescents have experienced increases in cigarette smoking, the prevalence of smoking among African-American adolescents has been consistently lower than that of whites (DPrevious studies (2,3) have not been able to explain why the race differential in adolescent cigarette smoking occurs. However, these studies have been crosssectional in nature and primarily examined only the contribution of sociodemographic and behavioral factors. In response, a prospective cohort study was conducted among AfricanAmerican and white adolescents who participated in both the first (1989) and the second (1993) waves of the Teenage Attitudes and Practices Survey (TAPS). The purpose of this study was to determine whether the race differential in the incidence of cigarette smoking is attributed to differences in sociodemographic, environmental, personal, or behavioral factors. TAPS was designed to provide national household-based smoking data on teenagers who were 11-18 years of age. The first TAPS (TAPS I) was conducted in 1989. The primary method of data collection was computer-assisted telephone interviewing. Teenagers who were not available by telephone were sent a mailed questionnaire. The eligible population included 12 097 adolescents. Of that number, 9965 interviews were completed either by telephone or by mail, with a resulting survey response rate of 82% (4,5). For TAPS II, interviews were conducted in 1993. Of the 9965 TAPS I respondents, 9135 were eligible (those completing a telephone interview) and 7960 (87%) teenagers participated in TAPS II (6). Given the 7960 participants, analyses were restricted to African-American and white adolescents (ages 11-17 years) who had never tried cigarettes at base line (n = 3531). Forty-seven (1.3%) respondents were excluded because of missing data on at least one study variable. Thus, the final study population consisted of 3484 adolescents for whom information was complete. Race was the exposure variable, and smoking status was the outcome variable. Based on two questions concerning main racial background and Hispanic origin, respondents described themselves as either non-Hispanic AfricanAmerican or non-Hispanic white. With respect to smoking status, respondents were asked the following questions: 1) Have you ever smoked a cigarette? 2) Have you ever tried or experimented with cigarette smoking, even a few puffs? Those who answered "no" to both questions were considered never smokers. Those who answered "yes" to either question were considered trial smokers. Control variables were categorized as sociodemographic (sex, age, and parental education), environmental (household smoking and number of same-sex friends who smoke), personal (five items on perceived benefits of smoking), or behavioral (intention to smoke, organized physical activity, and school performance). Weighted percentages were used to estimate the cumulative incidence of trial smoking for each population subgroup. Then, logistic regression analysis (7) was used to estimate the odds ratio (OR) of trial smoking for whites (compared with African-Americans) before and after adjustment for confounding factors. Logistic regression-model estimates were calculated with the use of SUDAAN, a procedure for analyzing complex sample survey data (8). After 4 years of follow-up, 30.0% of African-American adolescents became trial smokers compared with 43.1% of whites. The crude OR was 1.6 (95% confidence interval [CI] = 1.3-2.0). In Table 1, the crude OR was adjusted for multiple confounding factors. The adjusted OR of 1.8 (95% CI = 1.5-2.3) was virtually the same as the crude OR. Other predictors of trial smoking included household smoking, the number of same-sex friends who smoke, intention to smoke, and school performance. These data suggest that selected sociodemographic, environmental, personal, and behavioral factors do not account for the race differential in the incidence of adolescent cigarette smoking. The present findings are consistent with those of previous studies (2,3). One limitation of this analysis is a possible differential misclassification. African-American adolescents may be more likely to underreport their smoking habits than white adolescents (9,10), resulting in an overestimation of effect. Differential misclassification, however, is not likely to explain the race-smoking association. Investigators (9) have found that the race differential in adolescent smoking persists, even when biochemical measures of cigarette smoking are used. These findings underscore the need for more research on contributors to the race differential in teen smoking. African-American adolescents may be less likely to smoke than whites because of stronger actions against teen smoking by African-American parents (11-13), the belief among African-Americans that tobacco products are being marketed specifically to them (75), or a lower likelihood among African

BACKGROUND Congenital anomalies are a leading cause of infant deaths, accounting for almost a fifth of all infant deaths. Few studies have researched the survival experience of infants born with congenital anomalies past the infant stage. METHODS Using birth and death files routinely linked to the Michigan Birth Defects Registry, we identified all singleton infants during calendar years 1992 through 1998 with reportable congenital anomalies for our study. A comparative file of children born without congenital anomalies during the same time period was developed using linked birth and death files. The mortality data were assessed by age at death (through age six) and race to determine mortality rates, relative risks, hazard ratios, and survival trends. RESULTS Throughout early childhood, children born with congenital anomalies had a high risk of mortality compared with all other children. The overall 7-year hazard ratio comparing children with congenital anomalies with all other children was 7.2. Overall mortality rates for black children were significantly higher than white children through the age of seven, irrespective of whether they had congenital anomalies. Among children with congenital anomalies, this disparity disappeared after adjusting for birth weight, sex, mother's age, mother's education, and number of organ systems affected. CONCLUSIONS Compared with children without congenital anomalies, children born with congenital anomalies had a higher risk of mortality well beyond the infant period. Racial disparities in mortality rates among children with congenital anomalies were due to confounding factors. Birth Defects Research (Part A) 67656–661, 2003. © 2003 Wiley-Liss, Inc.

To evaluate the prevalence and trend of folic acid awareness among Michigan mothers during 1996-1999 and to identify maternal characteristics predictive of folic acid awareness.We analyzed data from the Michigan Pregnancy Risk Assessment Monitoring System, a population-based survey of women with recent live births. A positive response to the question, "Before you became pregnant, did you know that folic acid could help prevent some birth defects?" was used as an indicator of folic acid awareness. Logistic regression was used to evaluate trends in folic acid awareness prevalence and the association between folic acid awareness and certain maternal characteristics.Of the women invited to participate, 7252 responded (67.3%). Overall, folic acid awareness increased from 1996 to 1999 (60.3-71.4%; P.001). However, folic acid awareness decreased for women with no high school education from 1997 to 1999 (59.3-13.8%, P = .05). In addition, folic acid awareness was lower among black women (adjusted odds ratio [OR] 0.43; 95% confidence interval [CI] 0.4, 0.5, versus other races), women with unplanned pregnancies (adjusted OR 0.6; 95% CI 0.5, 0.8, versus those with planned pregnancies), and those with no high school education (adjusted OR 0.08; 95% CI 0.03, 0.2, versus women with college education).Although folic acid awareness has increased among Michigan mothers overall during 1996-1999, it has decreased among women with less than a high school education, and substantial gaps exist among socioeconomic subgroups. Continued efforts are needed to improve folic acid awareness and consumption of folic acid among women of reproductive age, with special attention focused on populations experiencing gaps or declines in folic acid awareness.

The magnitude of the effect of smoking duration on lung cancer mortality relative to that of intensity (cigarettes/day) has practical implications for both tobacco control policy and research. This issue was addressed by R. Doll and R. Peto (J. Epidemiol. Commun. Health, 32: 303-313, 1978) in their historic analysis of one of the few large cohort studies in which intensity and duration were estimated separately. Their findings have been interpreted to mean that smoking duration is much more important than smoking intensity in causing lung cancer. The separate contributions of smoking duration and intensity to lung cancer risk have not been evaluated in other large prospective studies. We studied participants in the Cancer Prevention Study II, followed from 1982 through 1988. After restricting to people 40-79 years old who smokedor =40 cigarettes per day at enrollment, we fit Poisson models for four age groups and evaluated lung cancer mortality (M) in relation to smoking duration (D) and intensity (I) on a double-log scale, as suggested by the Armitage-Doll multistage carcinogenesis model. The age-specific mortality estimates for men (M(m)) and for women (M(w)), when transformed to the original scale, were: ages 40-49: M(m) = e(-17.9) x D(1.9) x I(0.95), M(w) = e(-20.2) x D(2.8) x I(0.96); ages 50-59: M(m) = e(-17.4) x D(2.6) x I(0.52), M(m) = e(-17.2) x D(2.2) x I(0.75); ages 60-69: M(m) = e(-15.7) x D(2.4) x I(0.37), M(m) = e(-14.1) x D(1.5) x I(0.78); ages 70-79: M(m) = e(-13.0) x D(1.8) x I(0.39), M(m) = e(-13.2) x D(1.3) x I(0.95). Our study confirms that years of cigarette smoking is far more important than the number of cigarettes smoked per day in predicting lung cancer risk in United States men, regardless of age, and provides new evidence that a qualitatively similar pattern holds for women. The results support measures to prevent the uptake of smoking by adolescents and increase cessation. We discuss reasons why the associations we observe are lower than those reported by R. Doll and R. Peto (J. Epidemiol. Commun. Health, 32: 303-313, 1978).

To examine the relationship between interpregnancy interval and low birth weight (LBW), using the retrospective cohort design.We used the maternally linked Michigan livebirth data documented between 1989 and 2000 to evaluate LBW in relation to interpregnancy (i.e., delivery-to-conception) interval, overall and at levels of other reproductive risk factors. We fit separate logistic regression models for pairs of first-second, second-third, third-fourth, and fourth-fifth births to control for confounding.Of the 565,911 infants identified, 5.5% had LBW. Univariate and stratified analyses showed that the risk for LBW was lowest when the interpregnancy interval was 18-23 months, and increased with shorter or longer intervals. This J-shaped relationship persisted after controlling for all risk factors simultaneously. For example, among the first-second birth pairs, the adjusted odds ratios (AORs) for LBW associated with interpregnancy intervals6, 24-59, 60-95, and 96-136 months were 1.4 (95% confidence interval [CI] = 1.3-1.5), 1.5 (95% CI = 1.3-1.6), 1.1 (95% CI = 1.0-1.1) and 1.5 (95% CI = 1.3-1.8), respectively, compared with an interval of 18-23 months. Among the second-third birth pairs, the AORs were 1.5 (95% CI = 1.3-1.6), 1.3 (95% CI = 1.2-1.4), 1.1 (95% CI = 1.0-1.1), and 1.6 (95% CI = 1.3-2.0), respectively. Among the third-fourth birth pairs, the AORs were 1.2 (95% CI = 1.1-1.4), 1.3 (95% CI = 1.1-1.5), 1.0 (95% CI = 0.9-1.1), and 1.4 (95% CI = 1.0-2.0), respectively. Among the fourth-fifth birth pairs, the AORs were 1.3 (95% CI = 1.1-1.6), 1.2 (95% CI = 0.9-1.5), 1.1 (95% CI = 1.0-1.4), and 1.3 (95% CI = 0.8-2.3), respectively. The population attributable risk associated with interpregnancy intervals shorter than 18 months or longer than 23 months was 9.4%.These data suggest that spacing pregnancies appropriately could be used as a strategy for preventing LBW.

Objective: We evaluated interpregnancy interval in relation to adverse perinatal outcomes and whether the relationship differed by race. Study Design: We analyzed the vital statistics data for multiparous white and black women in Michigan who delivered a singleton live birth during the period 1993 through 1998, using stratified and logistic regression techniques. Results: Among women of both races, the risk for delivering low birth weight, premature, and small-for-gestational-age birth was lowest if the interpregnancy interval was 18 to 23 months. In comparison, among white women, the odds ratios for the 3 outcomes were 1.5, 1.3, and 1.3, respectively, if the interval was

Background A prolonged measles epidemic occurred in Wenzhou City, China after a nationwide measles mass immunization campaign (MMIC) in 2010. We conducted an investigation to identify factors contributing to this epidemic and to provide evidence-based recommendations for measles elimination strategies in China. Methods Measles was diagnosed using the national standard case-definitions. We estimated the population vaccination coverage based on the proportion of measles patients that had been vaccinated. In a case–control investigation, all measles patients who received treatment in The Second Affiliated Hospital of Wenzhou Medical College (Hospital S) during November 1 to December 31, 2010 served as cases; controls were randomly selected among all other patients who received treatment in Hospital S during the same time period, frequency matched by month of hospital visit. We reviewed medical records of case- and control-patients to compare their exposure history at Hospital S and to its intravenous rehydration room (IV room) during the incubation period (7–21 days before their illness onset). Results The attack rate of measles in Wenzhou City was 3.3/100,000 during September 1, 2010 to January 11, 2011. Children aged 8-11 m had the highest attack rate (171/100,000) of all age groups. In children not age-eligible for the MMIC but should have been routinely vaccinated after the MMIC, the vaccination rate was only 52%. In the case–control investigation, 60% (25/42) of case-patients compared with 21% (35/168) of control-patients had visited Hospital S (adjusted ORM-H = 5.5, 95% CI = 2.7–11). Among unvaccinated children who had received treatment in Hospital S, 84% (21/25) of case-patients compared 38% (11/29) of control-patients had visited the IV room (adjusted ORM-H = 9.2, 95% CI = 1.5–59). Conclusion Relaxed routine measles vaccination among children after the MMIC was the main factor responsible for this epidemic. Exposure in the IV room at Hospital S facilitated the epidemic. To reach the goal of measles elimination, the Chinese public health authorities should make greater efforts to improve timely routine measles vaccination, and to reduce nosocomial transmission.

We examined the impact of the heptavalent pneumococcal conjugate vaccine (PCV7) on hospital discharge rates for invasive pneumococcal disease among Michigan children younger than 5 years old. After the introduction of PCV7, the hospital discharge rate for children younger than 1 years old was significantly lower than before introduction. We correlated the decreased rates with the introduction and rapid uptake of PCV7. Lack of change in the hospital discharge rates for other age groups likely represents a slower uptake of PCV7 compared with that for children aged younger than 1 year.

Prevalence, behavioural patterns and risk factors of cigarette smoking were studied in a sample of 8437 junior high school students in Beijing in 1988. Smoking at least occasionally was reported by 34.4% of boys and 3.9% of girls, though the intensity tended to be low. Smoking prevalence increased with age among boys. Inhaling smoke into the lungs was practised by 68.2% of the boys who smoked and 37.3% of the girls. 'Believing that one looks elegant when smoking', 'trying to be fashionable' and 'seeking stimulation' were the most important reasons for smoking. Of the boys 83.5% and of the girls 86.5% usually smoked with friends or schoolmates. Many more boys (19.2%) than girls (1.7%) smoked at home. Examinations of risk factors for teenage smoking showed that it was associated with a combination of familial, psychological and socio-school factors, with peer group pressure being the most important one.